NURS 2100 Exam 4 Material PDF

NURS 2100 Exam 4 Material Exam on Monday 1/26/25 Week 7 : Gas Exchange & Oxygenation Assessment Week 8 : Tissue Integrity Assessment Week 7 : Gas Excha...

NURS 2100 Exam 4 Material Exam on Monday 1/26/25 Week 7 : Gas Exchange & Oxygenation Assessment Week 8 : Tissue Integrity Assessment Week 7 : Gas Exchange & Oxygenation Structure & Function of the Lung - Composed of the upper & lower airways + Upper airway - Pharynx : the cavity posterior to the nose and throat - which is then subdivided into several regions - Nasopharynx : refers to the nasal area - Oropharynx : refers to the throat or mouth - Larynx : top of the trachea where the vocal cords are found These structures warm, filter, and humidify air taking through the nose & mouth + Lower airway - include the trachea, bronchi, bronchioles, alveoli of the lungs - The trachea divides into the bronchial tubes within the lungs, which are air-filled sacs that are primarily responsible for gas exchange in the body + Alveoli → where gas exchange occurs - R lung has 3 lobes; L lung has 2 lobes - Lungs are responsible for bronchoconstriction & bronchodilation + Bronchoconstriction : tightening of the bronchus due to the contraction of the smooth muscle + Bronchodilation : expansion of the airway in the bronchus - Pleural Cavity : the space between the visceral and parietal layers of the lungs; enables the lungs to expand and contract smoothie with pleural fluid production in this space - Pleura : the protective layer or membrane covering the lungs Physiology of Ventilation and Perfusion - Air moves in & out of the lungs through inhalation & exhalation, which are aided by the diaphragm and the intercostal muscles + Diaphragm : the muscle that separates the chest cavity from the abdominal cavity and innervated nerves; controlled by the autonomic nervous system; during inhalation, the diaphragm(moves down) and the intercostal muscle contracts  creating a negative pressure inside the lungs & thorax increase in size; during exhalation, the diaphragm moves back up (curved) - Surfactant : a lubricant made in the lungs to keep the alveoli from collapsing during exhalation; lack of surfactant in the lungs, there can be a loss of volume during expansion → collapsed lungs - Atelectasis : collapse of airways and small sections of the lung as a result of shallow breathing; the collapsing of the lung during expiration Gas Exchange - The lungs enable gas exchange between the cardiopulmonary system and the outside environment specifically the bronchioles and alveoli + Bronchioles → the large airways & bronchioles deliver the gas to the alveoli and the pulmonary capillaries through diffusion + Ventilation : the flow of air inside or outside of the alveoli; air flows into the alveoli while carbon dioxide is taken out + Perfusion : the flow of blood into the alveolar capillaries where deoxygenated blood is exchanged for oxygenated blood in the heart & delivered to the rest of the body Respiration - The amount of breathe per minute - The brainstem monitors the body’s oxygen demand and carbon dioxide levels and signals the respiratory system to respond to excesses or under-supply - Example : the rate and depth of respirations increase when a client’s feverish and exercising → more carbon dioxide to be exhaled and more oxygen to be inhaled - Normal range for an adult : 12-20 breath/ min Oxygen Transport - Vital to very bodily function carried out in the cells and organs - The cardiopulmonary system is responsible for oxygen transport via the arterial circulatory process, allowing gas exchange at the capillary level RBC (Erythrocytes) transport oxygen in their hemoglobin Regulation of Respirations - The respiratory drive is maintained by the peripheral chemoreceptors located in the aortic arch and carotid arteries, and the central chemoreceptors located in the medulla oblongata within the brainstem Lung Volumes - Lung Compliance : the point to which a lunch can expand in response to increase pressure within the alveoli (intra alveolar pressure) + Examples of causes : emphysema, COPD, pulmonary fibrosis, atelectasis can increase or decrease lung compliance  - Air way resistance : the pressure or opposition of the tissues in the airway to the flow of air - Inspiratory reserve volume : the amount of air breathed in after a typical inspiration - Tidal volume : volume of air inspired and expired at each breath - Residual volume : volume of air remaining in the alveoli after expiration - Forced vital capacity : the amount of air that can be expelled from the lungs in 1 second during forced expiration - Vital capacity : maximum volume of air that is expelled after maximal inspiration - Total lung capacity : volume of air remaining in the lungs after maximal inspiration Pulmonary Circulation The movement of blood from the heart to the lungs from the capillaries for gas exchange and back Myocardial Blood Flow  - Systole (S1) Contraction : + “LUB” + The AV valves (Tricuspid & mitral valves) close so the semilunar (aortic & pulmonary open) → pushing blood to the body + The heart muscle contracts and pumps blood out of the body - Diastole (S2) Relaxation : + “DUB” + The semilunar (Aortic & Pulmonary valves) close so the tricuspid & mitral valves open for the ventricles to refill with blood + The pressure in the heart when it’s relaxed + AV Valves Open; Semilunar closes Cardiac Output (CO) - The volume of blood pressure by the left ventricle in 1 minute - Regulated by the heart rate (HR) and stroke volume (SV) - Equation → CO = HR x SV Stroke Volume - The amount of blood that is ejected from the L ventricle during a contraction with ONE heartbeat or cardiac cycle - Factors affecting SV : + Pre-load : the blood remaining in the L ventricle at the end of diastole causing it to stretch + Afterload : the amount of resistance or force that occurs when the heart ejects blood from the L ventricle + Contractility : the force required to eject blood from the L ventricle Electrical Conduction of the Heart - Originates from the sinoatrial (SA) node located in the wall of the R atrium - The heart’s “pacemaker” - The electrical impulse moves from the SA node to the atrioventricular (AV) node → bundle of His → R and L bundle branches → Purkinje fibers = normal sinus rhythm Electrical Conduction Pathway Sinoatrial (AV) node → atrioventricular (av) node → bundle of His → R & L bundle branches → Purkinje fibers Cardiopulmonary Risk Factors Dietary Habits - Encourage diets rich in vegetables, fruits, fibers, whole grains, fish, and omega-3 fatty acids  - The DASH (Dietary Approaches to Stop Hypertension) diet and Mediterranean diet are encouraged to lower the blood pressure - Limit high amounts of sodium & added sugar & processed carbohydrates Exercise - Improved blood circulation throughout the body and strengthens the heart muscle - Exercising 30-60 minutes a day can lower the risk of cardiopulmonary disease (COPD) by lowering BP and cholesterol levels Smoking - Nicotine increases blood pressure and HR by vasoconstriction → reduces the oxygen level being delivered throughout the body Stress - Can raise blood pressure by triggering fight-and-flight response(sympathetic nervous system) → causes increase cortisol to be released from the hypothalamus of the brain - Chronic stress could affect one’s well being if not controlled Environmental Factors - Factors that could contribute to COPD include : pollution, second hand smoke, vehicles, occupational hazards, air particles Assessment of Cardiopulmonary Functions - Includes assessment of inspection, palpitation, auscultation, percussion of the heart & lungs - Collect the client’s & client’s family medical HX, RX history, & client’s social history like alcohol/ substance use, home environment, etc Physical Assessment - Objective Data + Overall appearance, LOA, signs of distress, weight, breathing, hygiene + Vitals signs, including oxygen saturation - Inspection + Note the client’s breathing patterns; Normal breathing [should be regular and quiet, no signs of discomfort] + Note signs of difficulty breathing such as use of accessory muscles, restlessness, cyanosis + Signs of chronic pulmonary disease → clubbing (enlargement of the fingertips) & edema (swelling) & barrel chest (rounded & bulging chest) + Observe for jugular vein distention → this can give information about the pressure and blood volume in the R side of the heart - To assess for this : recline patient to 30-45 degrees with the head turned slightly away from the examiner, using a ruler, the jugular vein is measured from the sternal notch to the highest point of the  pulsation; a measurement > 1.5 inches = abnormal distention and increased central venous pressure + + Observe if the patient is in a tripod position - Palpation (Feelings with the hands/ fingers) + Used to assess the carotid and apical pulses simultaneously → allows the nurse to assess and compare regularity and timing for the correct rate + Palpate the thorax for tenderness, respiratory excursion, and tactile fremitus → examine for inflammation, expansion, and symmetry while the client breathes + All extremities should be palpated for skin turgor, temperature, capillary refill, edema, and pulses - 4 point scale to measure pitting for edema → Slight imprint is +1 & a deep imprint is a +4 that slowly returns to usual + Tactile fremitus : vibration felt in the chest wall during palpation while the client is speaking - This could be caused by : Pleural effusion (a buildup of fluid in the pleural space) or pneumothorax (air in the pleural space causing the lung to completely or partially collapse) - - Percussion (beating or striking) + Accesses the cardiac border and identify any abnormal accumulation of fluid in the lungs + When over the border : the sound will turn from resonance to dullness when the percussion is over the border & over the lung fields with excess fluids are present - Auscultation (listening)  + Listen to the heart and lungs anteriorly, posteriorly, at the flanks to identity any abnormalities in the lung fields + Normal breath sounds include : bronchial (heard over the trachea and bronchi) & vesicular sounds (heard over lung tissue) Abnormal lung sounds - Crackles : sounds like popping and cracking; caused by fluid filling the air sacs; results from those with pneumonia or an infection - Wheezing : whistling or musical nose during exhalation; caused by constricting airways; results from asthma & COPD - Ronchi : rattling sounds caused by obstruction of the airway; results from asthma and COPD - Strider : sounds like wheezing but is caused by constriction in the upper airways during inhalation; considered a medical emergency; results from inflammation of the epiglottis or by croup which is a viral infection - Murmurs : whooshing or blowing sounds (high, medium, low pitched) - Expected heart sounds includes S1 & S2 (LUB DUB) ; S3 and S4 (called gallops) are additional heart sounds that could be heard + S3 : sounds like “ken-tuck-y” - in children and athletes often benign, and can indicate heart failure in adults + S4 : sounds like “ten-nes-see” indicating of aortic stenosis, hypertension, or HX of MI Indications of Hypoxemia Hypoxemia : occurs when there is a decreased amount of oxygen in the blood; low amount of oxygen in the blood Hypoxia : below the expected level of oxygen in body tissue - Symptoms include : confusion, irritability, restlessness, dyspnea, tachypnea, tachycardia, bradycardia, cyanosis, flaring (in children), pursed lip breathing, intercostal retractions, use of accessory muscles Factors Affecting Oxygenation and Function of the Respiratory System - Results in hyperventilation, Hypoventilation, hypoxia Hyperventilation : an increase amount of carbon dioxide exhaled, leading to low levels of CO2 in the blood + Increase in rate and depth of breathing  + Causes blood pH to increase = alkalosis → resulting in weakness, dizziness, headache, anxiety, increased HR & difficulty breathing, tingling and numbness in the fingers + Example : anxiety attacks, infections like pneumonia, lung diseases like COPD and asthma, diabetic ketoacidosis, brain injury Hypoventilation : increase amount of CO2 in the blood and not enough oxygen + Shallow breathing with a low RR + Leads to acidosis with the pH decreasing + Symptoms include : anxiety, dyspnea with exertion, confusion, disturbed sleep patterns, weakness, impaired cough + Examples : neuromuscular disorders, certain RX, neurologic disorders, trauma Hypoxia : decrease of O2 levels in the cells + Decreased amount of O2 in the tissues + Causes : low number of RBCs to carry oxygen, decreased diffusion possibly caused by COPD and pneumonia, poor tissue perfusion, decreased ventilation; smoking, high altitudes + Patient should be given supplemental O2 and O2 levels be monitored closely Factors Affecting Cardiovascular Functioning - Includes : conduction or mechanical system of the heart, which can alter CO and tissue perfusion Disturbance of Electrical Conduction - Arrhythmias (dysrhythmias) : electrical impulses that are uncoordinated due to conduction abnormalities which disturb the rhythm of the heart → a fatal condition - Contractility examples include : heart failures, valvular diseases, and arrhythmias - Perfusion disorders examples include : hypertension, MI and CAD Bradycardia : a heart rate less than 60 BP + The heat is unable to pump effectively so the body tissues does NOT receive O2 rich blood + Symptoms include : lightheadedness, fatigue, chest pain, confusion, fainting (syncope), shortness of breath, tiring easily with exercise + Athletes may be effect but could be considered normal if they are asymptomatic Tachycardia : a heart rate of more than 100 BPM - The heart beats faster than expected and may not be able to pump blood to the organs & tissues of the body - Symptoms include : lightheadedness, fatigue, chest pain, heart palpitations, syncope (fainting), shortness of breath - TX Goal : identify the cause of the rapid HR and return it to normal sinus rhythm + TX suggestions : less caffeine/ alcohol; getting more sleep, no smoking, RX Atrial fibrillation : a rapid, irregular heartbeat that starts in the atria that is triggered by signals coming from outside of the SA node - Due to this, the AV nod biomes overwhelmed, and the atria do not contract but instead they quiver → causes blood clots to form from the pool of blood in the atria, which can then travel to other parts of the blood and block blood flow to other organs Ventricular dysrhythmias : electrical impulses begin the ventricle - Heart chambers are unable to fill with blood, resulting in blood not being pumped to the lungs and body - Symptoms : chest pain, dizziness, shortness of breath - Ventricular tachycardia : an arrhythmia that is caused by electrical signals coming the ventricles + could occur with or without a pulse Left-Sided Heart Failure + Affects the L ventricle + Alters the heart’s ability to pump blood to the rest of the body → causes blood back up in the pulmonary veins (not allowing blood to be carried away) Right-Sided Heart Failure + Affects the R ventricle + The heart is unable to effectively pump blood to the lungs → the blood is backed up into the systemic valves; due to the increased pressure in the veins, fluid will leave the veins to enter the tissues resulting in edema Valvular Heart Disease Regurgitation : leaking heart valves that do not close + Leads to backflow of blood and failure of blood to move forward + Could be auscultated as a murmur Stenosis : heart valve becomes narrow & stiff + Prevents blood from moving forward + Prolonged stenosis causes the ventricles to work harder to push blood forward → leading to enlarged (hypertrophy) ventricles, which can then lead to R or L heart failure + Impaired Tissue Perfusion (Hypoperfusion) - Occurs in the presence of hypotension - If prolonged, multiple systems in the body can be damaged due to the lack of blood flow including the heart, brain, and kidneys - This can be irreversible - 3 factors contributing to tissue perfusion : preload, contractibility, afterload + Distribution of any of these factors can decrease CO and lead to hypotension and impaired tissue perfusion - Symptoms include : chest pain, syncope, arrhythmias, changes of LOC, decreased urine output, lactic acidosis Myocardial Ischemia - Blood supply to the heart is decrease, the heart is not able to provide the body with high levels of O2 → resulting in decreased CO - Usually causes by a complete or partial blockage of the coronary arteries - Symptoms : angina, neck or jaw pain, fatigue, nausea, vomiting, tachycardia, arm/ shoulder pain, sweating - Untreated could lead to Myocardial infarction (MI) Angina Pectoris (Simply Angina) - A symptom of CAD (Coronary Artery Disease?) - Caused by a reduction in blood flow to the heart → creating chest pain and/ or discomfort because the O2 level is low resulting in the heart not function properly - Symptoms include : tightness, squeezing, heaviness in the chest, burning, fullness or pressure, sweating (diaphoresis), dizziness, fatigue, etc Myocardial Infarction - Irreversible damage to the heart due to decreased O2 resulting from ischemia Oxygen Delivery Devices - Supplemental oxygen may be required for clients with cardiopulmonary issues to achieve a fraction of inspired oxygen greeted then 21% (the % on room air); used to TX hypoxemia which requires a provider’s order since it is a RX - Normal O2 levels : 95-100% for a healthy adult // Illness adults : 88-92% Nasal Cannula : delivers O2 through the prongs inserted into the nares - Delivered at low concentrations 1-6 L/ min (24-44% of oxygen) Simple face mask - Delivers at a medium concentration 5-10 L/ min (35-60% of oxygen concentration) - Able to retain CO2 when the client exhales - A flowmeter helps keep the O2 flow at a constant rate  - Skin care should be provided to clients with long-term face mask due to risk of skin breakdown Partial Rebreather mask : like the simple face mask, but has a reservoir bag - Delivered at a high flow rate 10-15% L/ min (60-90% oxygen) - On inspiration, the client’s air is drawn into the holes of the mask and oxygen by the inflated bag; during exhalation, gases are sent to the reservoir or out through the holes of the mask & oxygen is drawn in from the inflated bag → when the clients inhales again, oxygen & CO2 are mixed Non Rebreather mask : like the partial rebreather mask but the valves are now going to the reservoir bag and holes in the mask - The valves ensure that exhaled gases are not returned to the bag - Delivered at high flow rate of 10-15% L/min (80-90%) Venturi Mask - Delivers at a high concentration 4-15% L/min (24-60%) - Includes barrels that deliver oxygen at high velocity along with room air Aerosol Mask - Used to administer nebulized solutions (RX that are changed from liquid form into mist) for the client to inhale - Used as a breathing TX like decreasing inflammation of the lungs; bronchodilators Positive Airway Treatment - A continuous positive airway pressure (CPAP) device : a machine with a hose and either a mask or a nosepiece that delivers a flow of constant & steady air, creating a positive pressure to keep the upper airway open + CPAP keeps the alveoli open and improves the amount of O2 in the client’s blood + Usually used as TX for obstructive sleep apnea (OSA), premature infants, and clients with cardiopulmonary diseases like stroke, hypertension, CAD + CPAP can be used with OR without supplemental oxygen - Bilevel positive airway pressure (BiPAP) : moves air through a tube into a mask that fits over a client’s nose + Pressure are higher when inhaling and lower when exhaling, compared to CPAP delivers a single pressure + Prescribed usually for patients with collapsed airways while sleeping causing them difficulty breathing & decreased air exchange in the lungs Apnea : a condition in which there is an absence of inspiratory airflow for a minimum of 10 seconds Complications of Oxygen Therapy Oxygen Toxicity  + Due to high partial pressures that cause oxidative damage to the cellular membranes → causing alveoli to collapse (adverse effect that can happen w/ in 24 hours to exposure of pure O2) - Acute Toxicity : affects the CNS; appears as twitching of the hand muscles, prolonged exposure leading to nausea, generalized convulsions, dysphoria, and tinnitus (ringing of the ears); Causes : stress, cold, increased CO2 in the blood - Chronic Toxicity : affects the pulmonary system including atelectasis (collapse of the lungs), coughing, dyspnea, pleuritic chest pain, heaviness substernally Therapeutic Interventions - Needed to prevent cardiopulmonary complications; including prevention and termination of disease & shortening the pathology of the disease Sputum Specimen Collection - Assists in the DX and TX of infectious pulmonary disease - Obtains a sample of the sputum to be examined in the lab - Suggested to be collected in the morning before eating & drinking, or when the client is able to produce a sample - Client is instructed to take several deep breaths to loosen the secretions and force a deep cough to move mucus from the lower respiratory tract Chest Physiotherapy (CPT) - Percussion of the chest, vibration, and postural drainage (facilitates expectoration of mucus due to gravity and permits removal of secretions from the airways) - Enhances the clearance of secretions from the lungs through the use of external mechanical maneuvers - Clients include : COPD, cystic fibrosis, pneumonia - This allows expansion of the alveoli within the lungs, decreased risk of infection, strengthening of the respiratory muscles - TX sessions usually lasts b/w 20-30 minutes, about 4 times a day Incentive Spirometer (IS) - Used to promote deep breathing; provides visual feedback to the client on the amount of inspiratory volume (amount of air breathed in after a normal inhalation) realized by inflating the lungs and being able to sustain the inflation - Could be used post-op to help with restoring the function of the lungs - Helps decrease the risk of atelectasis by mobilizing secretions from the lungs and promoting lung expansion Purse Lipped Breathing - Clients w/ chronic lung diseases such as emphysema, COPD, pulmonary fibrosis have a hard time breathing  - This technique helps with breathlessness; in such situations like exercise, and during labor intensive activities - Benefits : release air trapped in the lungs by keeping the airway open for easier breathing, slow the rate of breathing through prolonged expiration and move air out of the lungs so that air can enter to improve breathing patterns, alleviates shortness of breath & encourages relaxation Flutter Valve - A device that is used as breathing therapy; allows breathing to be more comfortable and makes it easier to clear mucus in the lungs, reducing & preventing atelectasis & reducing air trapping in the lung - Allows clients to cough up the mucus & clear up the airway - Clients include : cystic fibrosis, chronic bronchitis, cardiopulmonary diseases Coughing & Deep Breathing - Important to clear the lungs of mucus/ pus & to prevent atelectasis and pneumonia - Aids in the expansion of the lungs and clearing secretions - Those should be mindful after SX coughing since the sutures and incisions can open and pull apart (dehisce); to avoid this, clients should use a pillow for splitting their abdomen & chest for support Huff Coughing - Consists of inhaling air and holding it, which allows the air to propel the removal of mucus from the lung walls and be expectorated - Similar to exhaling onto a mirror or steaming up a window; a cycle of 4-5 huffs should be performed to clear the airways Suctioning - Could be performed through the mouth (oropharyngeal), nose (nasopharyngeal) or artificial airway like tracheostomy, nasotracheal, or endotracheal tube - Helps clear the airway & can prevent respiratory infections and other respiratory complications - Allows improvement of client’s oxygenation and decreased respiratory effort due to the removal of secretions - Completed by intermittent suctioning, performed for 10-15 seconds Nasotracheal Tube (NTT) - Artificial airway passed through one of the nares, the nasopharynx, and into the trachea - Sterile technique through an open or closed system Endotracheal Tube (ETT) - Artificial airway inserted through the mouth past the vocal cords into the trachea - Keeps the airway open, protects it against aspiration, and ensures oxygenation and ventilation - Complications include : bleeding, infection, perforation of the oropharynx, hoarseness (vocal cord injury), damage to teeth/ lips, esophageal placement  Tracheostomy - Open-system tracheostomy suctioning (the method we did in lab) - Long-term airway management device that is inserted into a trachea through a surgical opening in the front of the neck below the vocal cords - Procedure techniques : + Suctioning equipment should be used as aseptic (clean) for closed system & septic for open system + Client should be hyperoxygenated before the catheter is placed inside the tracheostomy tube prior to placing the catheter on intermittent suction Chest Tube - Inserted in the pleural or mediastinal space of the thorax of the client to allow for drainage of blood, fluid, or air - Goal is to facilitate lung expansion and to restore normal intrapleural pressure - Procedure : Following insertion, the chest tube is connected to 3 chambers + First chamber (collection chamber) : the drainage from the chest tube is collected + Second chamber (water seal chamber) : allows air to exit the client’s chest during exhalation and stops air from entering when the client’s inhales; sterile water is injected into the chamber and is assessed for tidaling → bubbling indicates air leak may be present + Third chamber (suction chamber) : wet suction - filled with sterile water to the appropriate level for the amount of suction prescribed; dry suctioning - does not require anything to be inserted into the chamber and acts as a regulator of suction once the system is attached to wall suction + Assessment includes : vital signs, breath sounds, oxygenation, respiratory efforts, the amount, color, consistency of drainage in the chamber (odor is not documented unless a sample is collected) Week 8 : Tissue Integrity Factors Contributing to Tissue Integrity Skin - the largest organ system of the body; accounts for 15% of total body weight - Main function : provide a barrier against injury, infection, ultraviolet radiation (UV), and fluctuations in temperature changes; perception of touch, pain, pressure, and vibrations, eliminating waste, support of underlying structures, and production of vitamin D & A Skin Anatomy & Functions - Skin consists of 3 distinct layers : epidermis, dermis, and hypodermis (fatty subcutaneous layer of adipose tissue) Epidermis - Outermost layer of the skin - Contains different cells : + Keratinocytes : cells formed in the basal layer of the skin that function to protect the skin from the external environment like water loss, pathogens, and injury; with time the cell dies and are removed from the skin by shedding + Melanocytes : produce melanin which is a pigment that determines the color of the hair, skin, and eyes; absorbs radiant energy from the sun and protects the skin from harmful UV rays - Melanin : pigment that determines the color of the hair, skin and eyes + Merkel Cells : receptor cells that detects light touch, especially in the palms of the hands and soles of the feet + Langerhan Cells : ingest and package foreign antigens to be presented to lymphocytes, which then trigger an immune response in the epidermis Dermis - Thicker layer of the skin found under the epidermis composed of connective tissues along with capillaries, blood vessels, and lymph vessels - Consists of two regions : + Superficial papillary & deep reticular; the papillary region contains fibroblasts that release hyaluronic acid & fibronectin which promotes the healing of wounds - Protects underlying structures from injury and assist with wound healing; collagen and elastin fibers provide strength and elasticity, so without these there could be tissue integrity Hypodermis (Subcutaneous Tissue) - Composed of mostly adipose tissue, found under the epidermis & dermis - Insulates the body, absorbs shock, and pads the internal organs and structures - Contains blood vessels and nerves that assist in thermoregulation and sensation Risk Factors for Impaired Tissue Integrity - Risk factors include : infancy/ early childhood stages when the skin is immature: + Maceration : an irritation of the epidermis cause by moisture + Dermatitis : a red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound secretions/ exudates; also called irritant dermatitis - Risk factors include : Later in life that contribute to collagen stores decrease, the skin thins & loses elasticity and tissue trauma; Skin exposed to the sun may exhibit premature wrinkling, accelerating the aging process + Skin tears : loss of top layer of the skin cause by mechanical factors; the severity of a skin tear is defined by the depth of the skin layer loss - Risk factors include : impairments in mobility such as congenital conditions like spina bifida and cerebral palsy, and chronic diseases like liver failure, kidney disease, cancer → All contributing to skin frailty (at- risk for vulnerable skin) - Most common skin problem w/ skin frailty are skin tears, pressure injuries & cellulitis - Pressure Injuries : localized damage to the skin and/ or underlying tissue, which can be caused by prolonged contact with a firm surface that interferes w/ circulation to the area - Cellulitis : an infection of the superficial layers of skin Important to implement holistic measures and actions to maintain the integrity of the clients’ skin through regular skin assessments, observations of environmental factors, and diligent implementation of prevention measures → decrease clients’ risk for developing skin breakdown Skin Assessment - Key to promoting optimal skin health → regularly assessing the skin of clients who are vulnerable to the development of alterations of the skin & tissue integrity like client’s overall status including nutritional & mobility - Major elements to include : medical HX, factors of places that place the client at risk, assessing the skin for abrasions, edema, moisture, rashes, and other abnormalities, skin texture & temperature - Skin & soft tissue assessment is also important to decrease the risk of pressure injury formation, classifying wounds and determining TX modalities - Head to Toe Assessment : should be done to examine the bony prominences for manifestations of erythema + Erythema : redness of the skin due to dilation of blood vessels & other tissue discoloration + Blanchable Erythema : redness of the skin that temporarily becomes white or pale when pressure is applied but the area turns to red when the pressure is released (NORMAL)  + Nonblanchable erythema : redness of the skin that does not go away when pressure is applied, which indicates that structural damage has occurred in the small vessels supplying blood to the underlying skin & tissues - Skin temperature should be palpated since it can increase with an infection, however, decrease blood flow will feel cool to touch - Obese clients : it is important to assess for the presence of pressure ulcers between the skin folds of clients who are obese due to the increased pressure caused by the weight of the additional fat; they are at increased risk for moisture-related skin disorder/ infections - Skin under any medical devices should be check regularly to prevent skin changes & pain at pressure points Different Types of Skin Conditions in Light/ Dark Skin Tones Refer to chart in textbook w/ photos Types of Wounds - Wounds: a disruption in the normal composition and performance of the skin & its underlying structures; could be classified as acute or chronic based on their origin & healing progression Acute Wounds - May originate either intentionally or unintentionally + Intentionally : such as those created during a SX procedure + Unintentionally : result as a traumatic injury like burns, punctures, or gunshot Trauma Wounds - Lacerations : usually caused by blunt or sharp objects; they could have irregular & jagged shape; Lacerations could be classified as simple or complicated Skin Tears - Caused by mechanical forces such as removing tape from the clients’ skin - Severity is determined by the depth of skin loss which can occur on any body of the body but mostly found on the upper and lower extremities and back of the hands Surgical Wounds - Acute wounds that are created intentionally during SX - Classified as : clean, clean-contaminated, contaminated, or dirty + Clean & clean-contaminated : minimal bacterial loads and are closed at the completion of the procedure + Contaminated & dirty : higher bacterial loads that may interfere w/ heading - SX wounds are created under serial conditions, most oftenly closed with staples, sutures or a surgical skin adhesive + Should have intact, well-approximated edges  + Color of the incision changes as the wound heals - Day 1-4 : incision is red - Day 5-14 : bright pink - Day 15-1 year : pale pink + SX site could have edema (swelling) & exudate (fluid consisting of plasma that is secreted by the body during the inflammatory phase of healing) but should decrease and resolve by day 5 post operative + Epithelial closure usually happens on day 4 & wound closure materials usually are removed in 10-12 days depending on the SX Moisture-Associated Skin Damage (MASD) - Form of dermatitis that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates - Risk factors : Excessive sweating, increased local skin temperature, abnormal skin pH, and deep skin folds, pressure injuries - Symptoms : pain, burning, itching Chronic Wounds - Develop over time as a result of disruption in the wound healing process associated with acute wounds, or due to conditions that cause alterations in the blood flow + Conditions include : chronic venous insufficiency, peripheral artery disease, diabetes mellitus + Risk factors : older adults & smokers - they are undernourished, immunosuppressed, immobilized, or have an infection in the wounds → greater risk for developing chronic, non healing wounds - Important to distinguish pressure injuries from lower extremity wounds due to chronic conditions + 3 major categories for chronic lower extremity wounds w/ different etiologies - Venous disease wounds, arterial disease wounds & neuropathic disease wounds → predispose clients to develop pressure injuries Wound Assessment - During dressing changes, wounds should be assessed for manifestations of healing & infection; assessing color, amount, and odor of exudate - Exudate Categories : + Serous : thin, watery wound drainage + Serosanguineous : thin, watery wound drainage mixed w/ blood + Sanguineous : blood wound drainage + Purulent : green/ yellow wound drainage; indicates infection Wound Measurement - Should be measured by facility policies - Common methods used include : tracing the wound circumference and calculating the wound surface area using see-through film & measuring the length & width of the wound  using a ruler - whichever method is used should stay consistent throughout the TX process - To measure the wound depth & tunneling → gently inserting a sterile pre moistened cotton tip applicator under the wound edges until resistance is felt; the depth is marked on the applicator then measured w/ a ruler or depth can be measure only w/ a ruler + Tunneling : development of a narrow channel or passageway extending in any direction from the base of the wound + Undermining : open area extending under intact skin along the edge of the wound Pressure Injury - Developed due to prolonged pressure over an area of the skin or due to a combination of pressure and/ or shearing + Shearing : a force parallel to the surface of the skin; occurs when clients are sitting or lying on an incline since gravity pulls deeping tissues downward while the top layers of the skin remain in contact with the surface on which the client is sitting; this could result in stretching and trauma to the blood and lymphatic vessels - Could occur more often over bony prominences, but could appear where medical devices are used such as urinary catheters, oxygen tubing, endotracheal tubing, SX/ wound drains Risk Factors Contributing to Pressure Injury Development - Factors include: + Immobility + Malnutrition + Reduced perfusion + Altered sensation + Decreased level of consciousness + Exposure to moisture + Tearing, cuts + Bruises + Friction (force created when 2 objects rub together) - not a direct cause to pressure injuries but causes trauma to the skin & tissues increasing the risk for developing pressure injuries Braided Hair - those who have these TIGHTLY can lead to occipital pressure injuries leading to scarring, alopecia, or permanent hair loss; those who are admitted to the hospital with these usually have them loosen/ removed by the nurse to decrease the risk of occipital pressure injury Location of Pressure Injury Formation - Most susceptible for pressure injuries → bony prominences such as heels, toes, sacrum, hips, elbows, shoulders, back of the head, knees  + In these areas, pressure is applied to where the lower layers of tissue receive the most pressure, resulting in greater damage to the deep tissue where bones & muscle meet which might not be visible from the surface Risk Assessment - This begins the process of decreasing the risk of pressure injury - Assessment includes : + Immobility : one of the greatest factor contributing to pressure injuries, without mobility, pressure is consistently exerted in one area & not relieved + Malnutrition : low albumin levels, maintaining weight w/ a healthy dietary intake is the strongest preventative measure for tissue integrity + Reduced skin perfusion (Hypoperfusion) : low oxygen levels due to poor circulation which can occur who acute blood loss and/ or low BP; low oxygen levels in the tissues w/ prolonged pressure can result in tissue break down in less than 2 hours + Sensory loss : occurs w/ neurological conditions such as delirium, dementia, peripheral neuropathy, spinal cord injuries, pain related to pressure sensation Braden Scale - Valid & reliable risk assessment tool for use in hospitalized clients - Rates a client’s risk for alterations in tissue integrity using 6 categories : sensory perception, moisture, activity, mobility, nutrition, friction & shear - Lowest score is 6 & maximum is 23 ; the lower the score = the higher the risk for alterations in skin and tissue integrity - Note: this scale does not mention hair braids, so it is important for nurses to still observe the clients for outside parameters of the Branden scale to allow for a more thorough assessment Stages of Pressure Injuries - Categorized into stages according to the amount of skin and tissue damage observed - Observe for : non-blanchable erythema, the amount & depth of skin and tissue loss, the condition of the tissue in the wound bed and surrounding areas, the presence of dead tissue, and tunneling & undermining + Undermining : an open area extending under skin along the edge of the wound - Once assessed, the wound will be rated on a scale of 1-4 - the TX plan will vary per stage + Stage 1 (Non-Blanchable Erythema) : skin is intact w/ localized area of non-blanchable erythema; sensation, temperature & color change, could be touch to detect in darker-pigmented skin + Stage 2 (Partial Thickness Skin Loss) : pink or red viable tissue in the wound; tissue is moist, but deeper tissue is not visible; may also present as a ruptured serum-filled blister  + Stage 3 (Full Thickness Skin Loss) : visible adipose tissue; present granulation tissue which is new skin forms on the surface of the wound; undermining & tunneling may be present - Granulation Tissue : new skin tissue that forms on the surface of the wound + Stage 4 (Full Thickness Skin & Tissue Loss) : fascia, muscles, tendons, ligaments, cartilage, and/ or bones are visible - Benchmarking : comparing results and outcomes to other sources of similarly retrieved data; it shows the facility if its overall pressure injury prevention initiatives are successful Unstageable Pressure Injury : Obscured Full-Thickness Skin & Tissue Loss - Full damage in the wound bed; obscured full-thickness skin & tissue loss injury - Usually covered in slough or eschar + Slough : yellow, stringy nonviable tissue found in the base of the wound + Eschar : hard nonviable black/ brown tissue found in the wound bed; if removed, the wound will reveal a stage 3 or 4 pressure injury Deep Tissue Pressure Injury - Persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color - A result of intense and/ or persistent pressure and shearing force Device Related Pressure Injury - Could be caused by medical devices, equipment, furniture, or everyday objects that are left in direct contact with the client’s skin - If this injury occurs, it is called : a medical-device related pressure injury (MDRPI) - Often used : oxygen masks, oxygen tubing, urinary catheters, cervical collars, compression stockings, any device in contact with the skin Mucosal Membrane Pressure Injury - Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device - Includes the lining of the respiratory tract, gastrointestinal tract, genitourinary tract - Medical devices that can potentially cause damage : respiratory equipment, feeding tubes, drainage tubes Hospital Acquired Pressure Injury (HAPIs) - Occurs during hospitalization & is considered a hospital-acquired condition - Increased risk include : patients in critical care settings, prolonged hospitalization with chronic disease like diabetes mellitus, kidney diseases - Medicare/ Medicaid limit federal reimbursements for HAPIs for stage 3 & 4 Classifying Pressure Injuries in Darkly Pigmented Skin - Possibly first indicators : skin temperature and level of moisture in the wound  - Other indicators : edema, hardened skin, localized pain - Those with stage 1 or deep pressure injuries, the nurses should assess the adjacent skin area that is darker than the surrounding skin Documentation of Pressure Injuries - Documentation should include : location, stage, size; description of the tissue, the color of the wound bed, the condition of the surrounding tissue; the appearance of the wound edges; the presence of undermining and tunneling; and any foul odor present - Note: older adults, especially with dementia, are at risk for under-assessment & under-TX of pain when they are unable to advocate for themselves Types of Wound Care Surgical Debridement - Debridement : Process of surgically removing dead tissue and other debris that can cause infection + Decrease the number of bacteria in the wound & stimulates wound closure & epithelization + Chronic wounds should be debride multiple times before healing occurs - Dead tissue & accumulated debris (also called biofilm) are removed with a scalpel or scissors Irrigation - Removes surface materials and decrease bacterial levels in the wound - Could be performed at the bedside or the surgical site, depending on the amount of pressure needed to irrigate the wound - 0.9 sodium chloride is used Biological Debridement - Various enzymatic agents can be applied to wounds to clear dead tissue and debris + Includes : collagenase, papain (papaya extract), bromelain (pineapple extract) + Collagenase : an agent that targets only necrotic tissue helps promote wound healing by facilitating keratinocyte and endothelial cell migration across the wound; also an alternative TX for clients who need wound debridement but not SX candidates - Larvae therapy : helps stimulate wound healing and has antimicrobial actions + a larvae of the green bottle fly & the Australian sheep blowfly secrete an enzyme that liquifies necrotic tissue + The dead tissue is then ingested by the larvae while the health tissue is left untouched Wound Dressing Types  - Careful selection helps facilitates : wound healing, minimizes scarring, strengthens tissues as it heals - Depending if the wound is acute or chronic, it’s important to select the correct dressing to address the needs of the wound itself + Ideally, the dressing should assist & soak up excessive moisture for wound healing, decrease the probability of maceration of surrounding tissue while leaving the adequate moisture for the wound to heal Clean vs. Sterile Dressing - Sterling dressing → applied after SX and usually kept on the incision site for 24-48 hours + If it becomes too saturated or loose, the dressing is changed using sterile technique - After 48 hours, wounds are managed using clean technique, since the wound is considered to be colonized from the client’s environment + Home wound care can use clean technique Dry vs. Wet Dressing - Dry vs wet dressing depends on the wound type & provider preference + Dressing change depending on the provider’s prescription, mostly done daily, every 2 days, or as needed due to excessive drainage - Wounds covered by dressings usually health faster compared to those that aren’t covered Wound Dressing (Moisture-Retaining Ability) - Depending on their moisture retaining ability, they can be classified into 3 categories : + Open dressing - Gauze bandages are considered open dressings; these are considered wet to dry dressings since it is usually soaked with 0.9 sodium chloride then packed into wounds to assist with debridement by removing the attached tissues to the gauze; a disadvantage is that not only does necrotic tissue gets removed, but also granulation (new) tissue does too + Semi-open dressing - Consists of 3 layers; first layer : a layer of knit gauze that is more closely woven than traditional gauze infused w therapeutic ointments; middle layer contains padding and absorbent gauze; the final layer is adhesive; these do not control draining well and put the client at risk for poor wound healing & breakdown of tissue adjacent to the wound + Semi-occlusive dressing : ability to cover wounds and control moisture & bacteria; Variety includes : - Films : - advantages include the ability to allow moisture to evaporate while still maintaining a moist wound bed & the ability to allow oxygen to enter the wound while decreasing the risk of microorganism to enter the wound; if  used with wounds with significant amount of exudate, leakage can occur and cause skin maceration & injury to the epidermal layer + Transparent Dressings : self-adhesive are used for covering superficial wounds that have minimal exudate - Hydrocolloid : used for small abrasions, superficial burns, pressure injuries, and post-op wounds; this gel-like dressing occludes the wound, maintain a moist wound bed, have bacteriostatic properties, and stimulate growth of new granulation tissue; + disadvantages could include : foul-smelling, yellow, gelatinous film that develop as bacteria are trapped in the dressing - Alginate : recommended for moderate to highly exudative wounds; provides hemostasis, high absorptive abilities, and can remain in a wound for several days + Disadvantage includes : a secondary dressing is required to cover the alginate, increasing the overall cost of wound management - Hydrofiber : used for moderate and highly exudative wounds; provides high absorbency and can stay in the wound for several days; draws less fluid from the wound edges, resulting in less maceration around the wound compared to alginate dressing - Foams : used for mild to moderate exudate but requires more frequent dressing changes compared to others; could produce malodorous discharge + According to Blagrove, application of silicone-foam dressing to the client’s sacrum w/ in 24 hours of admission reduces HAPIs - Polymeric Membranes : usually used in mildly exudative wounds; stimulates growth and new epithelium, does not stick to the wound bed resulting in less trauma to the new granulation tissue - Hydrogel : can be used to manage dry wounds for debridement of necrotic tissue and eschar (dead skin healing over a wound than can fall off); these contains water to provide moisture to or draw moisture away from the wound depending on the needs of the wound; has a soothing or cooling effect and cause little trauma to the wound bed - Antimicrobial : agents like iodine, silver & honey can be added to dressings + Idoine : antiseptic that cleanses the wound + Honey : manage or prevent wound infection & decrease odor + Silver : effective on moist wounds with exudate or wounds with infection to attack bacteria Superficial Drainage - Film Dressings Mild Drainage - Polymeric Membrane  Mild to Moderate Drainage - Foams Moderate to Severe Drainage - Alginate, Hydrofiber Wound Closure Sutures & Staples - Main role : to keep wounds secure and intact - Abdominal, chest, and wounds without infection usually use this type of wound closure + Generally, stapes are NOT used for the face or neck - Benefits : placed more rapidly than sutures; healing is faster, usually within 7-14 days which then the staples are removed - this process could could potential damage to the skin, scarring, bleeding & infection - Staples are made from synthetic materials such as nylon & polyester or from natural fibers such as silk, linen and dried animal intestines + Synthetic and natural sutures can be absorbed or nonabsorbable; synthetic can dissolve within days to weeks, but lasting up to 2 months + Nonabsorbable could increase prolonged pain and suture sinus at the site of injury Skin Adhesive - Used as alternatives to sutures and staples - Save time in placement and the wound infection rates and cosmetic look of the incisions are comparable to those achieved w/ other techniques - Forms a protective waterproof covering around the wound - Used for small, minor wounds including those with straight edges; suitable for wounds on the face, head, parts of the arms, legs, and torso but not used over joints - Usually applied in 3-4 layers Negative Pressure Wound Therapy (NPWT) - Assist in the healing and closing of large wounds by reducing edema surround the wound and increasing granulation tissue formation - A foam dressing is applied over the wound and covered by a semi-porous occlusive dressing to which suction is applied constantly or intermittently depending on the wound/ client’s needs Wound Drains - Used to decrease accumulation of fluid, reduce accumulation of air, and collect wound drainage for testing and identification - Classified as either : passive or active based on their mechanism & open or closed + Passive drains : such as Penrose, rely on gravity to remove accumulated fluid from the body cavity or wound  + Active drains : such as postable wound bulb suction devices, use negative pressure to suction drainage from wounds or body cavities + Open drains : remove fluids to the air + Closed drains : send fluids to a closed containment system; requires smaller incisions and are less likely to become contaminated with bacteria - Types of drainage depends on the anatomic location of the SX, the wound type, the client’s individual needs, and the expected volume of drainage + Drainage is usually removed in a 24 hour period between 30 -100 mL or depending in provider’s preference + Early removal can cause hematoma (accumulation of blood in the body) and/ or seroma (collection of serous fluid) Complications of drains → clot formation at the insertion site, small tissue fragments that obstruct the tubing and prevent the outflow of drainage, and accidental removal of the drainage tube Types of Drains Penrose Drain - A type of passive, open drain - no collection chamber for wound exudate - A flat, pliable passive drain that uses gravity to drain accumulated fluid - An open drain made of corrugated rubber that is kept outside of the wound by attaching it with a safety pin Portable Wound Bulb Suction Device - A type of active closed drainage - Uses negative suction to drain fluid from the wound - Composed of a tube that has a bulb connected at the distal end; the tubing is inserted into the wound, while the bulb remains outside the wound, suction is created by pressing the sides of the bulb together and closing the port on the bulb to maintain the suction, as fluid is suctioned, the bulb expands - The bulb should be emptied at least every 8 hours or when it is more than half-full Large Bottle Drainage - Used for a large amount of fluid; consists of a higher-pressure large bottle - A silicone drain with a bottle Circular Portable Wound Suction Device - A drain in which the drainage tube is attached to a container with a spring inside; the spring expands as the container draws fluid out of the wound Drain Monitoring and Care - Drainage collection device begins collecting drainage immediately after its placement - Begins as sanguineous (bloody) drainage that progresses into more serosanguineous appearance as the wound heels  - Documentation should include : drainage type, amount, consistency, and odor - Some tenderness and edema at the insertion site are expected findings for the first several days after the drain’s insertion - Observe for : kinking of the tubing, regularly empty the drain, ensure that suction is maintained **See Regan’s Notes for Promoting Skin Integrity & Healing - Universal measures for prevention & TX; Wound Healing Process** (see pages below) ↓ Complications of Wound Healing - Factors include : decreased blood supply & perfusion of oxygen to the wound, long-term steroid use, aging, chronic conditions such as diabetes mellitus & malnutrition Local/ Systemic Infections - All wounds contain microbes, but not all wounds are infected - TX : antibiotics recommended for wounds that look clinically infected - Symptoms : cellulitis, redness around the wound, skin that is warm to touch, exudate, and foul odor - Systemic Infection indicators : risk for sepsis, fever, chills, nausea, vomiting, hypotension, high blood sugar, increased WBC, change in mental status Surgical Site Infections - The CDC defines it as infections related to operative procedures that occur near the surgical incision site within 30 days of the procedure + Deep incision surgical site infections : infections related to operative procedures that occur near the surgical incision 30-90 days after the operative procedure - Most common cause → Staphylococcus aureus, commonly found in nose and on the skin Wound Culture Collection - Collected by using a sterile cotton applicator, needle aspiration, or tissue biopsy - If using the sterile cotton swab, clean the wound with 0.9 sodium chloride first and then obtain a sample of the wound without touching the swab to surrounding tissue, after place the swab in a solution that keeps the swab moist Dehiscence - A complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly due to poor surgical technique, infection - Causes a mortality rate of 16% - Complication could occur 7-10 days after SX w/ serosanguineous discharge from the wound + If dehiscence occurs, notify the provider, cover the wound with a sterile dressing that is moistened with saline & prepare the client for a possible return to the operating room Evisceration - Protrusion of internal organs through a surgical wound which has dehisced or opened - Occurs when the wound and all layers of tissue under the wound separate resulting in protrusion of intra abdominal organs through the suture line = immediate attention Bleeding/ Hemorrhage - Bleeding that may occur internally or externally after an injury or surgical incision - Clotting cascade : blood vessels in the wound constrict to provide homeostasis and stop the bleeding + Platelets accumulate at the site of the bleed, triggering the release of growth factors that initiate the healing process → morning new matrix from fibrins which stabilizes the wound Hematoma (accumulation of blood) & seroma can occur if the blood-clotting mechanisms fails - Depending on their size, these collections of fluids may cause the incision to separate, placing the wound at risk for infection, as bacteria can then enter the deeper layers of the wound and infect the accumulated fluid - Due to the increase pressure and compression of the blood vessels cause by hematomas and seromas, wound ischemia could occur leading to tissue necrosis   Type of drain selected depends on the anatomic location o/t surgery, the wound type, the = client’s individual needs, & the expected volume of drainage  Drains are usually removed when the total wound drainage for a 24-hr period is between 30-100 mL o Early removal of drains has been associated with hematoma (accumulation of blood in the body) & seroma (collection of serous fluid) formation a. Penrose drain  A flat, pliable passive drain that uses gravity to drain accumulated fluids  There is no collection chamber for wound exudate  To collect drainage, a perforated 4x4 gauze is placed around the drain & fluids are collected directly onto the gauze  Sterile dressing should be maintained at the site for 24-48 hrs b. Portable wound bulb suction device  An active, closed system drain that uses negative suction to drain fluid from the wound  Composed of a tube that has a bulb connected at the distal end  The tubing is inserted into the wound while the bulb remains outside  Suction is created by pressing the sides o/t bulb together & closing the port on the bulb to maintain suction  Bulb should be emptied at least every 8 hours or when it is more than halfway full  After emptying, nurse should document the date, time, color, & volume o/t fluid collected c. Large bottle drainage  Used when a large amount of fluid is expected  Bottle is changed when half-full & the nozzle is expanded  Document amount, color, & volume collected d. Circular portable wound suction device  A special type of wound drainage system that is designed to continuously suction drainage from a wound by providing low vacuum pressure O. Drain monitoring & care  Fluid collected will likely begin as sanguineous drainage that progresses to have a more serosanguineous appearance as the wound heals  Nurse should monitor the amount of drainage & document the drainage type, amount, consistency, & odor  Nurse should also monitor skin around the drain site for maceration as well as lab work for manifestations of fluid & electrolyte imbalances  Inspect drain site for manifestations of infection, including pain, swelling, redness, & pus, & monitor the client for increase in body temperature P. Promoting skin integrity & healing a. Prevention  Consists of 2 main components: identification of clients at risk & implementation of interventions that are designed to reduce risk 1. Identification of clients at risk  Clients who are at risk include those who are malnourished, are immobile/have altered circulation or decreased sensory perception, have general physical/behavioral health disorders, or are experiencing incontinence   Braden scale should be used to identify clients at heightened risk for alterations in skin integrity  Should include a complete medical history, determination of level of risk using the assessment tool, a skin examination, & identification of previous pressure injury sites  Skin should be observed for maceration, erythema, rashes, & manifestations of infection  Should also be evaluated for incontinence, redness, or irritation a. Interventions for minimizing risk  Clients should be kept clean, dry, & repositioned frequently  If client is at high risk for pressure injury development, supportive surfaces, preventive dressings, toileting schedules, hydration, & nutritional interventions are implemented along with a mobilization plan b. Repositioning & early mobilization  Instruct & encourage clients to reposition themselves & change positions frequently  Record time & position client was placed in when repositioned  When positioned on their side, tilt client’s body at an angle between 20º-30º & support client with pillows  Early mobilization involves assisting & encouraging clients to move or shift into new positions to increase activity & mobility as rapidly as they can tolerate it 2. Other risk-minimization interventions  Correct position o/t bed  Supportive surfaces  Protection of bony prominences, skin, & mucosa under drains & other medical devices Q. Universal measures for prevention & treatment of tissue injuries a. Hygiene  Plan of care should address regular cleansing, especially after episodes of incontinence  Consider replacing traditional skin cleansers with pH-balanced foam cleansers  Care should also be taken to thoroughly dry folds in client’s skin  An individualized toileting plan should be developed to decrease episodes of incontinence to reduce risk for moisture-associated skin breakdown b. Hydration  Assists in the elimination of waste products as well as in the movement of nutrients throughout the body  To monitor manifestations of dehydration, nurses can assess for skin turgor, weight, urine output, elevated serum sodium levels, & serum osmolality c. Nutrition  Nurse should monitor client’s weight & oral intake frequently  Malnutrition should be considered when a client presents with unintentional weight loss  Nutrients essential for wound healing & tissue strengthening include protein, omega-3 & omega-6 fatty acids, & vitamins A & C  d. Circulation  When blood circulation is compromised, the body’s tissues su er ischemia (lack of oxygen), resulting in reduced nutrient supply to cells & failure to remove metabolic cellular wastes  Clients who are critically ill have an increased risk for impaired circulation due to their physiologically unstable hemodynamic status  Use of vasopressors places clients at risk for further circulatory problems R. Factors influencing wound healing  Diabetes mellitus decreases peripheral perfusion & impairs sensation  Infectious process breaks down collagen, making tissues more vulnerable to damage  Foreign bodies in the wound increase risk for infection  Steroids prevent the formation of collagen & fibroblasts  Malnourishment impairs the wound healing process by not providing su icient amounts of protein, calories, & vitamins/minerals  Tissue necrosis decreases blood supply to the wound  Hypoxia may be caused by vasoconstriction at the site of injury  When multiple wounds are present, each wound competes for nutrients needed for healing to occur, resulting in delayed wound healing at all sites S. The wound healing process  Dependent on factors including wound type, wound cleanliness, & the overall health status o/t client  Occurs in 3 di erent manners depending on type of wound & type of closure used: o Primary healing (AKA first intention) is a type of wound healing that occurs in clean lacerations & surgical incisions closed with skin adhesives or sutures  These are the fastest to heal o Secondary healing (AKA second intention) is a wound healing process that takes place when wound is left open to heal & granulation tissue forms from bottom up in the wound bed  Healing process is prolonged, & wound bed needs to be kept moist for proper healing to occur  Risk of infection is much higher as wound bed is in direct contact with the environment o Delayed primary closure (AKA tertiary intention) comprises a combo of primary & secondary healing, in which wound is left open for 5-10 days before it is closed with sutures  Decreases risk of infection in wounds that were not considered clean at the time tissue injury occurred a. Phases of wound healing  Occurs in 3 phases: the hemostatic/inflammatory phase, the proliferation phase, & the remodeling phase o Hemostatic/inflammatory phase begins the moment injury occurs & lasts 3- 6 days  Early in this phase, blood vessels constrict, & damaged tissues release proteins that trigger the activation of various clotting factors that work together to stop bleeding at the site of injury  When bleeding is controlled, histamine is released, resulting in vasodilation & increased capillary permeability   This increases blood flow to the injury, allowing for WBCs to flood the area & clean the wound  The presence of neutrophils has been shown to enhance the release of cytokines, increase fibroblast & keratinocyte production, & aid in tissue maturation o Proliferation phase begins 3 days after the injury & can last up to 24 days  Blood supply to the wound continues to improve  Granulation tissue develops simultaneously with new blood supply  Presence of collagen strengthens the wound & allows it to mature & wound closure to begin  Re-epithelialization occurs as keratinocytes around the periphery o/t wound begin to move into the center & fill it o Remodeling/maturation phase begins around day 21 and can last for more than a year  Collagen formed in the granulation tissues o/t wound is replaced with stronger collagen, aiding in wound maturation  Myofibroblasts secrete proteins that produce contractile force pulling the wound edges together T. Local/systemic infections ⑤  All wounds contain microbes but not all wounds are infected  Clinical manifestations of localized wound infection include cellulitis, redness around the wound, skin that is warm to touch, exudate, & foul odor  Indicators that infection has become systemic (client is at risk of developing sepsis) include fever, chills, nausea, vomiting, hypotension, high blood sugar, increased WBC count, & change in mental status U. Surgical site infections  CDC defines superficial surgical site infections (SSIs) as infections related to operative procedures that occur near the surgical incision site w/in 30 days o/t procedure & deep incision surgical site infections as infections related to operative procedures that occur near the surgical incision 30-90 days after the operative procedure  Most common causative agent of SSIs is Staphylococcus aureus bacterium V. Wound culture collection  Wound cultures are collected using a sterile cotton applicator, needle aspiration, or tissue biopsy W. Dehiscence  A complete or partial separation o/t suture line & underlying tissues that occurs when a wound fails to heal properly due to poor surgical technique, infection, or presence of foreign particles in the wound  Is a potentially serious complication that has a mortality rate of about 16%  Generally occurs 7-10 days after surgery, & is often proceeded by a serosanguineous discharge from the wound X. Evisceration  Occurs when the wound & all layers of tissue under the wound separate resulting in protrusion of intraabdominal organs through the suture line  Is an emergency situation that requires immediate medical attention Y. Bleeding/hemorrhage  Hemorrhage: bleeding that may be either internal or external  nur2100 exam 4 jeopardy review  What is the dietary sodium recommendation for cardiac patients? Less than 2300 mg  What does PICOT stand for? Population, intervention, comparison, outcome, time  Older clients have increased gag reflex? False  What do the Merkel cells of the epidermis do? Detect light touch  2 signs/symptoms of oxygen toxicity? Twitching, convulsions, nausea, ringing in the ears  Where does diffusion of respiratory gases occur? Capillary beds o/t alveoli  What is the first step of EBP? asking a question  List 2 signs/symptoms of sleep apnea? Fatigue, headache, depression, irritability, decreased sex drive, restlessness  What is known as the pacemaker o/t heart? SA node  S1 heart sound is caused by what? Tricuspid & mitral valves closing  What chamber of the heart pumps blood into the lungs? Right ventricle  Left sided heart failure causes fluid to backup into the? Lungs  What percentage of our total body weight does the integumentary system account for? 15%  Define general blood flow of arteries vs veins? Arteries go away from the heart & veins go toward the heart  Name 2 ways to increase effectiveness of communication with a patient who is hard of hearing? Speak slowly, face the patient, concise & clear speech, regular tone of voice  Name the 4 stages of wound healing? Hemostasis, inflammation, proliferation, maturation/remodeling  List 2 risk factors for formation of pressure injuries? Immobility, age, BMI, friction, nutrition, incontinence, altered mental status, altered sensory perception  Name 2 objective physical signs of COPD? Barrel chest, clubbed fingers, accessory muscle use  What chamber of the heart pumps blood into systemic circulation? Left ventricle  Define healing by first intention? Wound edges are approximated & closed  Name an open drain that passively drains? Penrose  Name 2 common pressure injury sites? Sacrum, heels, scapula, elbow  What stage is a large open wound with visible adipose tissue? Stage 3  What stage is a red, non-blanching wound with skin intact? Stage 1  What stage is a wound bed covered is escher, unable to see depth? Unstageable  What stage is an open wound, full thickened skin loss with bone visible? Stage 4  What stage is an intact blister on a bony prominence? Stage 2 engage funds Gas Exchange - oxygen toxicity includes ringing In the ears ; including headaches , - discoloration muscle twitching what substancesIs required to keep the client's alveoli from collapsing e causing at electasis ? surfactant - client's heart sounds e hears a low-pitched whoosing / blowing sound over the apex of the heart - Murmur (could be low medium , , high-pitched How to Measure Cardiac output (CO) CO = HR o SV Patient has Hx of asthma is wheezing ; what action should the nurse take first? - ascultate the lung sounds - document the respiratory rate Obtain the oxygen saturation - - check capillary refill Expected findings of COPD clubbing of fingers - Left sided heart failure expected finding - crackles In the lungs ; causes the blood to back up into the pulmonary circulation Note : R-sided heart failure - causes blood to back up Into the systemic Veins causing lower extremity edema Group of patients on a cardiopulmonary unit ; you should plan to see which patient first? a client who requires teaching about a new chlosterd - towering RX a client who reports dyspnea to the When walking - bathroom (shortness of breathe - a client who has a new DX of aortic value stenosis e needs a referral to a cardiologists - a home client who has. asthma e being discharged to Instructions to use an incentive spirometer - Inhale into the spirometer use every hour while awake - - hold breath for 3-5 seconds during use - use 10 times per session